Key ResponsibilitiesClaim & Pre-Authorization Management
- Processing pre-authorization requests for cashless treatments.
- Reviewing medical documents to ensure policy compliance.
- Submitting final claim files to insurance companies timely.
- Resolving claim queries or discrepancies raised by insurers. [1, 2, 3, 4]
- Hospital Billing Coordination
- Preparing accurate In-Patient Department (IPD) and Out-Patient Department (OPD) bills.
- Verifying medical charges, doctor fees, pharmacy items, and implant costs.
- Checking co-payment rules, room rent capping, and non-medical exclusions.
- Reconciling outstanding payments from diverse TPA companies. [1, 2, 3, 4]
- Patient Care & Communication
- Counseling patients regarding their specific insurance coverage limits.
- Assisting with hospital entry and discharge formalities smoothly.
- Addressing patient queries regarding deduction or claim rejection reasons. [1, 2, 3, 4]
- dministration & Portal Management
- Operating diverse TPA portals to track real-time claim status.
- Maintaining up-to-date knowledge of healthcare insurance norms and ICD codes.
- Generating monthly review reports tracking settlement efficiency. [1, 2, 3]